How did the project come about?

Frail, older people living in care homes have high levels of health and personal care needs. In Gateshead, 1500 people currently live in care homes.

Newcastle Gateshead CCG recognised that there was a need to improve the care delivered to their care home residents through the introduction of enhanced primary care support, multidisciplinary management and anticipatory care planning. This new model of care has improved the quality of care delivery to care home residents and has seen a sustained reduction in hospital admission from the care home population over a number of years. It was this that led to them becoming part of the national Care Home Vanguard Programme.

One of the key elements of the programme has been to improve the health and wellbeing of care home residents through changing care delivery and the introduction of technology enabled care solutions [TECS]. On the basis of this a piece of work is underway linking nutrition and hydration care and TECS. Metrics for the whole programme have been agreed with NHS England and in relation to this work particularly the focus is on reducing avoidable hospital admissions for those with urinary tract infections [UTI].

The maintenance of good hydration and nutrition status in older people living with frailty, i.e. those living in care homes has been promoted through a ‘food first’ approach. This has been successful in reducing avoidable hospital admissions for those with a UTI and has seen a reduction in the prescription of oral nutritional supplements for care home residents. Aside from the introduction of TECS to support nutrition and hydration the CCG are also introducing TECS alongside recognition of the deteriorating patient through the use of the national early warning score [NEWS].

To help embed a food first approach within the wider workforce, the CCG developed a technology programme to roll out tablets, apps and associated nutrition and hydration guidance/education into care homes. Initially the focus has been on the introduction of national early warning score into care homes as risk assessment tool to support clinical decision making and the development of a nutrition and hydration app to support care home staff in their daily practice.

The apps and technology have been developed in partnership with Solcom.

The programme

We know that illness in old age doesn’t always present in the same way as it does in younger adults, with older people living with frailty you often see functional changes first- so it is useless to look at observation changes if you don’t know that the parameters are different in this group of people.

— Lead Nurse, Care Home Vanguard Programme

As a consequence of the above a key aspect around the implementation of NEWS is evaluating the relationship between an individual’s NEWS score, level of frailty, cognitive impairment, functional abilities and treatment outcomes. A comprehensive evaluation of the programme to help understand the impact and benefits of introducing the technology is being undertaken by Northumbria University.

The CCG understood the importance of working with care homes to promote the benefits of using the technology, understand their needs and to identify any technological and operational barriers that could impact on introduction of the technology.

In terms of rolling out of the programme, the CCG has funded a practice educator (a nurse by background) as per the recommendation made by Northumbria University in the conclusion of a parallel piece of work undertaken regarding workforce. The practice educators role is to lead on care home engagement, training and education of care home staff, and manage the roll out and implementation of the technology.

Introducing the Technology

The CCG is at the beginning of rolling out the programme. There’s been quite a lot of preparatory work over the last year and lots of knowledge gained to support an effective roll out programme.

Newcastle Gateshead has also linked in with neighbouring CCGs who have looked at introducing technology including NEWS scores to help them identify key successes and challenges to inform how the technology is developed and the programme rolled out.

When looking at development of the nutrition and hydration app and the functionality required, the CCG took time to understand the care home requirements (i.e. local authority and CQC standard inspection requirements), as well as what they wanted to achieve. The CCG also undertook a comprehensive literature review in partnership with Northumbria University in order to understand the evidence and knowledge base which was used when developing the contents of the app.

It needed to be useful to care homes and cover areas that they needed as well as what we needed. We understood this is a journey we will need to go on, so we won’t be able to answer all the questions straight away. It’s not as straightforward as just introducing the technology, you need to work with care homes to understand the issues they encounter and develop the app with them. As a Vanguard Programme we have a lead for stakeholder engagement who has established a network of care home ‘champions’ who were also part of developing the technology so as to provide further assurance that it would meet their needs as well as be a valuable addition to care delivery.

— Therapy Lead, Care Home Vanguard Programme

The plan is roll out the technology (tablets and apps) to all care homes within a year. The first five care homes will act as a pilot and on evaluation recommendations will be taken into account for the wider rollout.

I think the other thing that’s worthwhile floating is the value of relationship building. Because this tech stuff is new even to very experienced care deliverers. It’s even more challenging for those who are part of the care homes. Who can be viewed as on the periphery and therefore haven’t really been included in massive system change initiatives previously.

— Lead Nurse, Care Home Vanguard Programme

Technology

Some of the care homes don’t have Wi-Fi. Each care home has different technology in terms of IT, equipment and what’s available. Alongside the project we need to understand how each care homes is set up in terms of IT. How advanced they are, how keen they are to get involved in the project. It’s called a ‘digital maturity assessment’ which is the buzz word for this sort of assessment to understand where they are.

— IM&T Lead, Newcastle Gateshead CCG

Providing them with the tablet and with a sim card, means they have access to 4G - so they will all be able to use the technology wirelessly. The only problem will be if a care home is in a ‘black spot’ where there is no access to a wireless or broadband signal. I don’t think we will come across this as a major issue. The chances of these factors all coming together will be quite low.

— IM&T Lead, Newcastle Gateshead CCG

In that scenario, we would need to see if they could operate offline using the tablets and then they could be docked, for example, with a network cable but we will deal with that if and when we come across it. The advantage of rolling out the technology in batches is that we can deal with these issues as we come across them, rather than a blanket roll out. We can adapt as we go along.

— IM&T Lead, Newcastle Gateshead CCG

Evaluation

In terms of introducing technology into care homes, two evaluations are being undertaken. One regionally by a consortium of universities regarding technological use and the context of wiliness/readiness to change.

The second evaluation is specifically related to the CCGs work regarding NEWS and hydration and nutrition as described above and will include ‘observed practice’ and holding ‘focus groups’ with care home staff. The remit is to explore the role of digital and technology solutions in relation to key aims and objectives of the programme.

This will include reviews of care home documentation and qualitative semi- structured interviews with key stakeholders.

In terms of return of investment, this won’t be available until final programme evaluation given older people with complex needs need multi-faceted approaches to be at their optimum levels of health and wellbeing. Therefore, improvements in avoidable hospital admissions have to be considered alongside the use of alternative services such as dietetics, GPs and community nursing. Notwithstanding are the quality outcomes such as those reported by patients and their families as well as the care home work force.

Throughout the Vanguard process, the CCG is considering sustainability for the project.

There is a cost for the tablets, so how does this get picked up? We have the Vanguard funding to cover the cost of developing the app and introducing technology into the care homes, but what happens after that?

There maybe an issue from a commissioning point of view as we have provided the tablets to the care homes. There is an expectation that they will take responsibility for those devices, which will be addressed going forwards. This includes looking at how care homes could use the technology to identify other issues that would be useful for them e.g. falls prevention and management.

Challenges

The challenge is the technology hasn’t been evaluated and there is so much pressure to introduce these things without understanding whether it will make a good positive difference; economically, and in terms of safety, quality and experience.

— Lead Nurse, Care Home Vanguard Programme

That’s why it’s so hard to talk about things like return on investment – you can’t separate it from the other changes we are putting in place and therefore it’s hard to evaluate it at this stage. That’s why it will need a full evaluation. And we can’t anticipate the financial return before rollout.

— Business Intelligence Lead, Care Home Vanguard Programme

Key learning

Don’t believe the headlines; expect impressive changes from initial pilots but always seek robust evaluation and enquire about sustainability and long term gains.

Don’t underestimate the value of work force engagement which is crucial for successfully testing out any new concepts such as the above.

Consider investing in a practice educator or similar dedicated post to introduce new concepts such as the above.

Find your champions; those who truly understand the needs of older people and the complex system needed to meet their complex needs e.g. Newcastle Gateshead CCG has a Pathway of Care group to help develop the clinical elements of the programme [as well as forums for residents, their families and the work force through other work streams]

Remember that all the Care Home Vanguard metrics relate to clinical care delivery hence without the knowledge of clinical engagement superstars who understand scientific evidence, softer intelligence /knowledge, pathway development and evaluation methods, the process and learning may not be as robust

Learn from when technology introduction hasn’t worked e.g. what is different on this occasion is that it’s not being rolled out by technological people, its being rolled out by a clinical person going out and talking to other clinical people which it is anticipated will make the difference between the equipment being used in the right way, rather than being left in a cupboard as has happened with other such projects.

Leaders:

Lesley Bainbridge, Lead Nurse, Care Home Vanguard Programme, leads one of six work streams; Pathway of Care, focusing on all clinical aspects of the programme